Nokea
The nurse is giving unlicensed assistive personnel directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus. Which instructions would be most effective for reducing infection?
- A. Assist the client to the shower and provide directions to use antibacterial soap
- B. Delay the bath until the client has received antibiotic therapy for 24 hours
- C. Use a bath basin with warm water and a new washcloth for each body area
- D. Use packaged pre-moistened cloths containing chlorhexidine to bathe the client
Correct Answer: D
Rationale: Chlorhexidine cloths effectively reduce MRSA. Antibacterial soap is less specific, delaying the bath is unnecessary, and a bath basin risks contamination.
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The nurse is preparing to change the wound dressing for a client who is receiving negative pressure wound therapy. Which of the following actions should the nurse take? Select all that apply.
- A. Administer pain medication 30 minutes before the procedure
- B. Apply skin protectant to intact skin surrounding the wound
- C. Cut the foam dressing to the shape and size of the wound
- D. Ensure that the prescribed negative-pressure setting is applied
- E. Verify that the occlusive film dressing is free of air leaks
Correct Answer: A,B,C,D,E
Rationale: All actions are correct: pain management , skin protection , proper foam sizing , correct pressure , and leak-free dressing ensure effective therapy.
Which oxygen delivery system would the nurse apply that would provide the highest concentrations of oxygen to the client?
- A. Venturi mask
- B. Partial rebreather mask
- C. Non-rebreather mask
- D. Simple face mask
Correct Answer: C
Rationale: Non-rebreather mask. The non-rebreather mask has a one-way valve that prevents exhaled air from entering the reservoir bag and one or more valves covering the air holes on the face mask itself to prevent inhalation of room air but to allow exhalation of air. When a tight seal is achieved around the mask up to 100% of the oxygen is available.
The nurse is caring for a client who is experiencing the cardiac rhythm shown in the ECG strip below. The nurse should recognize that the client is experiencing
- A. atrial fibrillation
- B. ventricular fibrillation
- C. sinus bradycardia
- D. normal sinus rhythm
Correct Answer: B
Rationale: Ventricular fibrillation is a life-threatening arrhythmia requiring immediate intervention. Atrial fibrillation , sinus bradycardia , and normal rhythm are less urgent.
During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence?
- A. What degree of supervision for basic care do you think you need?
- B. Let's review your skills check-list for type and level of skill
- C. Are you comfortable working independently?
- D. What client care tasks or assignments do you prefer?
Correct Answer: B
Rationale: The nurse needs to know that the employee has competence in certain tasks. One way to do this is to do mutual review of documented skills.
A 15-year-old primigravida is admitted with a tentative diagnosis of HELLP syndrome. Which laboratory finding is associated with HELLP syndrome?
- A. Elevated blood glucose
- B. Elevated platelet count
- C. Elevated creatinine clearance
- D. Elevated hepatic enzymes
Correct Answer: D
Rationale: HELLP syndrome is characterized by hemolysis, elevated liver enzymes, and low platelets. Elevated hepatic enzymes are a key finding, so D is correct. Answers A, B, and C are not associated with HELLP syndrome.